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Researchers estimate that by 2030, the demand for hip and knee replacements will grow astronomically – by 174% for total hips and by a whopping 673% for total knees. We’ve already witnessed this curve happening, and the growth is capturing everyone’s attention – especially that of CMS.

In turn, Medicare poses an essential question: how can we reduce costs across the country and equal the playing field for these procedures?

One solution is bundled payments. Bundled payments look at the entire episode of care, and this requires paying considerable attention to the outliers that increase costs, such as inpatient rehabilitation and hospital readmissions. It also means seeking out new ways to improve surgical efficiency and improve the patient experience overall.

In a recent webinar sponsored by Wellbe, Dr. David A. Fisher, orthopedic surgeon with OrthoIndy, shared his best practices for building a successful hip and knee replacement practice while accommodating for today’s growing patient population.

Adapting a Data-Driven PracticeDr. David Fisher

Achieving excellence in surgical management means providing high quality care with compassion and empathy, Dr. Fisher explains, and this can only be accomplished by addressing one patient at a time.

Of course, in order to measure your success, you need to adapt a data-driven practice. This is the only way to know if you are reaching your goals and performing at the level you strive for. It requires having a system in place to monitor outcomes, perform quality assessment, and activate quality improvement initiatives.

“We’re in this transformation agenda, where everybody wants more evidence. Payers want more evidence that we’re doing the right procedure on the right patient and getting the right outcomes. There are more stakeholders involved now than ever before,” says Dr. Fisher. “Transparency is a growing concern, and more measurements are being reported.”

Collecting Data for Quality Assessment and Improvement

In order to look at the total cost of care, it’s important to look at all phases that occur across the episode. This includes looking at outcomes data with Patient-Reported Outcomes, tracking complications, and conducting risk profiling to understand which patients are most likely to have complications.

Dr. Fisher began collecting data in his practice in 1988, using scannable forms. His research assistant would scan and verify all forms, then store them in an Access database. These forms collected the following information:

  •      OR data – personnel, anesthesia, turnover times
  •      Implant specific data
  •      Surgical technique data
  •      Hospital data – length of stay, discharge disposition, complications
  •      Outcomes data – complications, readmissions, revisions

Here are some key lessons Dr. Fisher learned about using Patient-Reported Outcomes for quality improvement along the way.

Achieving Surgical Efficiency

The first observation Dr. Fisher made upon assessing the data collected was the variation in the OR room. At the time, he was new to surgical practice and had just started working in a large hospital setting. He worked with different anesthesiologists every day. And he was amazed at the time variation from case to case – taking anywhere from 90 to 130 minutes. Upon further investigation, he identified several significant factors, including who the anesthesiologist was, and who was on the OR team.

As a surgeon, increasing volume was a key objective for Dr. Fisher and for the hospital. He wanted to find a way to maximize OR efficiency and increase the number of cases per unit of time. His solution was to pursue a team approach in the operating room. He created a team of high performance individuals who understood the key goals and were eager to participate; and he began working alongside the same anesthesiologist, the same scrub team, and the same circulators every day.

Over time, Dr. Fisher continued to collect and assess the data, noticing a steady improvement in volume, as well as a high level of efficiency. Turnover times dropped, complication rates decreased, and Dr. Fisher found he was doing as much work as he did 25 years ago in half the time.

Decreasing Risk of Readmission

When we consider the population that has a greater risk of increasing costs, it’s most often the elderly and those suffering from comorbidities such as obesity and diabetes. The challenge is finding a way to optimize the medical conditions for this population and therefore reduce the risks of excess costs.

Dr. Fisher’s data showed that patients with a BMI over 40 had a seven-fold increased risk of infection compared to other patients. But rather than eliminate those patients from his practice, he tried taking them through a different protocol, which included offering bariatric counseling for those who wanted to lose significant weight.

Over time, Dr. Fisher found these adjustments had a significant impact on the care provided for patients with a BMI over 40. Not only did his team significantly decrease the risk of readmission for wound problems, but they also dramatically decreased the risk of deep infection and other medical complications.

Improving Patient Experience

Dr. Fisher continued to perform patient studies, including a study in 2004-2005 looking at satisfaction after a total knee replacement. While 85% of patients surveyed were very satisfied with their outcome, 10% were better but not totally satisfied, and 5% reported being dissatisfied. Upon further investigation, the data showed the patients that were dissatisfied faced major complications, pain, or stiffness. And many of those suffering from pain or stiffness complained at 12 months post-op.

This group had great looking x-rays, Dr. Fisher explains. The question was: why were they having such poor results? After further examination, he found female patients had twice the chance of being unsatisfied with their total knee replacements. Patients who previously had knee surgery had an even higher risk of being unhappy. And those with a history of depression, pulmonary disease, and diabetes or worker’s compensation cases were also at a higher risk of being dissatisfied.

Thanks to this information, Dr. Fisher and his team were able to employ new strategies to find out how to optimize results for these patients.

Refining Patient Education

In the early 90s, Dr. Fisher developed a manual called “Joint Efforts” to help educate patients pre-operatively. His team began better preparing patients with a total joint class in 1992. In ’93, they started a rehabilitation protocol, where patients would go to physical therapy and start practicing exercises preoperatively. Eventually, Dr. Fisher published a study on his results, which showed significant reduction in length of stay, and improvement in function in patients post-operatively.

But Dr. Fisher wanted more. Three years ago, his team deployed a range of online education tools using Wellbe ConnectedCare. This includes 32 preoperative models that are available to patients online on any device, with notifications by text or email, helping them to prepare for surgery.

They also have 19 postoperative modules, including weekly updates sent in the first few weeks after the patient goes home, explaining where they should be in their recovery, and providing tips and advice to improve their recovery over time.

Streamlining Data Collection, Assessment and Education

Throughout his experience collecting and assessing the data, Dr. Fisher discovered some fundamental problems:

a) There were thousands of patients to track and follow.

Obtaining and storing data was time-consuming and expensive. On top of that, obtaining the Patient-Reported Outcomes became problematic. Dr. Fisher found the EMR systems were lacking the research application and capabilities he was looking for. He also wanted to improve patient education with better options.

b) Quality assessment required linking disparate data sets.

The data across each phase of the episode are stored in different systems, and in order to achieve a clear understanding of the episode of care, Dr. Fisher had to find a way to link the data sets.

His solution to these problems was Wellbe ConnectedCare. He recognized that the web-based patient education workflow would allow his team to educate patients more effectively, and they could automate data entry of their pre-operative and post-operative surveys using iPads in the clinic.

It only took three months for Dr. Fisher and his team at OrthoIndy to make the transition and streamline their efforts using the cloud-based solution. Not only did going paperless significantly decrease the amount of time spent collecting patient information, but it also allowed Dr. Fisher and his team to merge the various data fields, improve patient education, and access the data in one clean dashboard.

“Evidence-based clinical results are certainly going to drive the future of healthcare,” says Dr. Fisher. “But in order to get there, we have to have the data and justify the use of the technology at hand.”


David A. Fisher, MD is an orthopedic surgeon in practice in Indianapolis with OrthoIndy, one of the largest orthopedic groups in the Midwest. He has been the Director of the Total Joint service at the OrthoIndy Hospital since 2005. Dr. Fisher is a member of AAOS, the American Association of Hip and Knee Surgeons, the Mid-America Orthopedic Association, and the ISMA. He is an assistant Clinical Professor at Indiana University, and has given numerous national and international presentations on hip and knee replacement, healthcare economics, and large group management. He is the current President of the OrthoIndy Orthopedic Research Foundation and past President of OrthoIndy. He is an active consultant with Depuy Synthes, and does receive royalties and consulting fees for certain hip and knee products.